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Date of Referral: ___ JHBMC CPP - INTENSIVE OUTPATIENT PROGRAM FOR ADULTS PATIENT REFERRAL FORM Client Name: Date of Birth: ____________________________________________________ ____________________________________________________ Insurance Provider: ____________________________________________________ Insurance ID #: ____________________________________________________ Address: Phone: ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ Referring Agency: ____________________________________________________ ____________________________________________________ ____________________________________________________ Referring Clinician: ____________________________________________________ Phone: ____________________________________________________ Referral Diagnoses: ____________________________________________________ ____________________________________________________ ____________________________________________________ Medications: ____________________________________________________ ____________________________________________________ ____________________________________________________ Is the client medication Compliant? _______________________________________ Reason for Referral (Please use this space to indicate why the patient is being referred to IOPA now. Include all pertinent information, listing patient’s current needs and all significant current symptoms.): _____________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Client’s Strengths: _____________________________________________________ ______________________________________________________________________ ______________________________________________________________________ What are your initial goals for treatment? ___________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Current Psychosocial Stressors: ___ Community ___ Economic ___ Housing ___ Legal ___ Work ___ Other: ___ Educational ___ Medical ___ Family ___ Peers/Social Explain: _______________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Barriers to Treatment: ___ No Barriers ___ Cultural/Religious ___ Educational ___ Housing ___ Peers/Social ___ Speech-Language ___ Work ___ Cognitive ___ Desire/Motivation ___ Family ___ Legal ___ Physical Disability ___Visual ___Other: ___ Communication ___ Economic ___ Hearing ___ Medical ___ Reading ___ Transportation: Explain Barriers:_______________________________________________________ ____________________________________________________________________________ ______________________________________________________________________ Current Living Situation: _________________________________________________ ____________________________________________________________________________ ______________________________________________________________________